Form 24 Sample Committee Self-Assessment Survey

Form 24
Sample Committee Self-Assessment Survey
Strongly
Agree
Somewhat
Agree
Disagree
Strongly
Disagree
Terms of Reference and Composition
1. The committee has clear and appropriate Terms of Reference.
2. The committee has the right number of members.
3. The committee has members with the skills and expertise that are
needed by the committee.
Committee Management
4. The committee meets at the appropriate time of day.
5. I received orientation to the committee that was helpful to me as a
member of the committee.
6. The committee is receiving the support from hospital management
that it requires.
7. Information is received sufficiently in advance of the meeting.
8. The committee meets the right number of times over the year.
Committee Effectiveness
9. The committee is working effectively.
10. The committee performed its annual workplan.
11. The committee is effectively performing its role in the
following areas: [List specific items from committee Terms of
Reference - this will be unique to each committee.]
Chair Effectiveness
12. The chair is prepared for committee meetings.
13. The chair keeps the meetings on track.
14. The chair fairly reports the committee’s work to the board.
15. The chair encourages participation and manages discussion.
Overall Committee Performance
16. Overall, I am satisfied with my contribution to the committee.
17. Overall, I am satisfied with the committee’s contribution to the
board.
Comments and suggestions for improvement to committee processes:
______________________________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________________
Date Completed: ________________________
*See over for note.
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Form 24
Sample Committee Self-Assessment Survey
Note to Reader
The purpose of a committee self-assessment survey is to assist the board in evaluating the committee’s Terms of
Reference, committee composition, the committee chair’s effectiveness and the support/resources provided to the
committee. Accordingly, the survey or questionnaire will usually ask questions aimed at evaluating the following:
• Committee composition and Terms of Reference
• Committee meeting management
• Committee contribution and effectiveness
• Chair’s effectiveness
The survey should be completed under the direction of the board chair or board Governance Committee.
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